Dentist Peter Yonan of Awbrey Dental in Bend describes how the oral appliance works to move the lower jaw forward to open a patient's airway while he or she sleeps. Sleep apnea occurs when a patient's airway is blocked during sleep.

Oral appliances like this one treat sleep apnea by moving the lower jaw forward, opening the airway so patients can breathe more easily during sleep. Pictured is the Suad device made by Detroit-based Strong Dental, which is sold at Awbrey Dental in Bend.

More dentists treat sleep apnea

Any patient who walks through the doors of Awbrey Dental in Bend — even if just for a cleaning — gets a questionnaire asking them how well they’re sleeping.

Dentist Peter Yonan, who owns the clinic, screens all of his patients for obstructive sleep apnea, a condition that causes breathing to be interrupted during sleep, producing gasping or snorting noises. Snoring is a common symptom. If untreated, it can increase the risk of heart attack, stroke or high blood pressure.

If Yonan’s screenings show the patient likely has sleep apnea, he sends the patient to a sleep physician for an official diagnosis.

“People may see their dentist more often than they see their physician,” he said. “So if a dentist can participate in a patient’s health in that we might screen for things and make referrals to physicians, ultimately, we’re taking better care of our patients.”

The proportion of dentists jumping into the business of screening for and treating sleep apnea, a medical condition, has skyrocketed in the past decade. Many patients who don’t respond to traditional treatment benefit from oral devices dentists provide. But experts are concerned that some dentists are overstepping their bounds in this area that blurs the lines between medicine and dentistry, a trend that could ultimately harm patients in the long run.

The Oregon Board of Dentistry has issued warnings to dentists it has caught diagnosing and treating sleep apnea directly, a practice that’s outside the legal scope of dentistry. Screenings like Yonan’s are permissible — and increasingly common — but only a medical doctor can officially diagnose the condition. The board so far hasn’t disciplined any licensees, but it has made its stance clear: Dentists cannot diagnose sleep apnea, and they can’t treat the condition unless it was diagnosed by a medical doctor.

“It’s a concern of the profession,” said Steve Timm, president-elect of the Oregon Dental Association and a Bend dentist.

Their ‘expertise’

Sleep apnea, estimated to affect more than 18 million Americans, happens when one’s airway gets blocked while they sleep. Oftentimes it’s because the person is overweight and additional tissue thickens the wall of the windpipe, making it more difficult to keep open, according to the National Institutes of Health. Sometimes it’s because the throat muscles relax more than normal. A long, bony neck can also make for a narrower airway.

The most common treatment for moderate to severe sleep apnea — and the one most doctors and dentists recommend first — is a continuous positive airway pressure (CPAP) machine, a mask worn over the nose and mouth during sleep connected to a hose that gently pushes air into the throat, keeping the airway open.

Several studies have shown that at least half — some say more — of all patients issued a CPAP machine stop using it within a year. For many, it’s simply too cumbersome to wear while they’re trying to sleep.

Plan B, then, is a retainerlike oral appliance patients wear in their mouths at night that opens the airway by pushing the lower jaw forward.

That’s where dentists enter the picture. They’re experts at fitting things over the teeth, taking impressions and working with appliances like night guards and retainers. They understand how the jaw moves and have studied the muscles used in chewing.

“That makes working with an oral appliance something that’s right in our area of expertise,” said Steve Carstensen, a dentist who owns a practice in Bellevue, Wash.

Carstensen is preparing to speak on the subject at the 2014 Oregon Dental Conference in April, where he’ll teach dentists how to incorporate sleep apnea treatment into their practices.

“So the physicians — who are really focused on getting their patients treated well — have reached out to dentists to say, ‘Can you help us with these patients?’” he said.

The U.S. Food and Drug Administration has approved more than 100 different oral appliances. Carstensen says each dentist should have at least three he or she is adept at using.

A relatively recent development has been the coverage of oral appliances under health insurance policies, even if the patient received the device from a dentist.

“That’s been a major push forward, too,” Carstensen said. “Folks don’t have to pay out of pocket for a very necessary medical device.”

Yonan sells primarily the Suad device, a commonly used oral appliance made by Detroit-based Strong Dental. Placing the device over a pair of model teeth, he demonstrates how the tiny silver contraption works to move the lower jaw slightly forward.

Depending on which device he sells, Yonan said they can cost anywhere from $1,000 to $2,500.

About a mile away, the oral appliances Timm’s office sells cost between $400 and $1,200.

Not so simple

David Dedrick’s job as medical director at the St. Charles Sleep Center in Bend and Redmond has him collaborating with several local dentists to treat patients’ sleep apnea.

But there are some he just won’t work with.

“There are a number of practitioners who have solicited me saying they want to fit oral appliances,” he said. “I ask them ‘How many have you done?’ They say, ‘Well, I did one for myself, one for my wife and I’m ready to start working.’ And I grimace and those are obviously practitioners I would not send someone to.”

Many sleep apnea experts agree dentists should seek additional training before they begin screening for and treating the condition. A 2010 survey of most of the country’s dental schools found students spent an average of 2.9 hours learning about sleep disorders. Many curricula don’t include them at all.

The American Academy of Dental Sleep Medicine offers courses on sleep apnea. Gail Demko, president of the academy, said membership in the organization grew from 300 in 2002 to just less than 3,000 today, an “explosion” she attributes to an increased awareness of sleep apnea and, for dentists, an opportunity to tap into a new patient population.

The job of a dentist is much different today than it was decades ago, Demko said. The reason: Fluoride toothpaste, a product that gained widespread use in the U.S. in the 1970s.

“If you look in your mother’s mouth and you look at yours, you see your mom has a lot more fillings than you ever had,” she said. “Fluoride is in everything — water, toothpaste. … All of a sudden, dentists find they’re not drill-them-and-fill-them doctors anymore.”

That’s driven them to become knowledgeable in new, complicated services to branch out their patient base.

Treating sleep apnea, if you’re a dentist, calls for collaboration with a medical doctor, a concept most dentists understand and abide by.

It takes a doctor to oversee the long-term management of sleep apnea, which requires looking at factors like a patient’s weight and cranial-facial anatomy, their symptoms and associated medical conditions such as snoring or heart conditions, and how severe the case is, Dedrick said.

“That in and of itself really is a full-time job. … It’s not as simple as saying, ‘Oh, you snore. Let’s put a mouthpiece in, and here’s your bill for what sometimes can be significant amounts of money,’” he said.

Oral appliances

Awbrey Dental’s sleep apnea screening begins by asking patients to rank the likelihood they would doze off in certain situations.

Carstensen, of Bellevue, Wash., recommends the STOP-BANG test, the name of which is an acronym for the topics its questions cover: snoring, tiredness, blood pressure, age, etc.

If a patient’s score indicates he or she isn’t getting enough sleep, Yonan sends him or her home with a pulse oximeter, a machine that measures the oxygen levels in the blood, and tells the patient to wear it while sleeping for three nights.

Yonan then has a wealth of information on whether the patient’s breathing is disturbed and for how long, whether he or she is getting enough oxygen and his or her heart rate, which can increase if the patient isn’t getting enough oxygen.

If all signs point to sleep apnea, Yonan sends the patient to a sleep doctor, who does more extensive testing to get a definitive answer.

But Demko, of the AADSM, says dentists should limit their screenings to a simple questionnaire. Anything more can invite problems.

Pulse oximeters don’t catch everyone who has sleep apnea, she said. In fact, Demko said, sleep apnea doesn’t always cause oxygen levels to drop at night among people younger than 45 and healthy older people. In those cases, they may not get referred to a doctor even if they have sleep apnea, she said.

“It is a misinformation if you don’t understand the disease,” Demko said.

If a patient scores well on the pulse oximetry report but has other symptoms of sleep apnea, Yonan said he’ll still refer him or her to a sleep doctor.

It would also be inappropriate for dentists to charge the patients for sleep apnea screenings, Demko said.

“The minute you say they don’t have sleep apnea based on the pulse oximeter, you have made a medical diagnosis and you’re way outside your scope of licensure,” she said.

Yonan said his office charges patients the $50 it has to pay a third-party company to interpret the data and create the reports. The office does not make money off the screenings, he said.

More dentists are getting into the practice of diagnosing sleep apnea on their own than Demko would like to believe, she said, and there are ongoing lawsuits to prove it. Sometimes, that’s because dental supply companies have sold the dentist diagnostic equipment that allows him or her to diagnose and treat sleep apnea without getting a doctor involved, Demko said. She declined to say which supply companies are engaging in the practice.

And each provider wants to pull people toward their method of treating sleep apnea.

Dedrick, of the St. Charles Sleep Center, said he often sees ads paid for by dental offices that say things like “Don’t like your CPAP machine? Well, come get my oral appliance. It’s so much easier.”

His response?

“An oral appliance is not a cakewalk, either,” he said.

Then there are the ear, nose and throat doctors, who tout their surgical procedures to widen the airway.

Research has shown that the long-term success rates of CPAP machines, oral appliances and surgeries all hover around 50 percent, Dedrick said.

“I want it to not be competitive but I suppose medicine has become somewhat of a competitive venue,” he said. “You see the ear, nose and throat surgeons saying ‘Well, we’ll do something for a surgical solution.’ But, again, that’s far from perfect, either.”

Obesity is the biggest risk factor when it comes to long-term sleep apnea, but Dedrick said he’s respectful of how challenging it is to lose a significant amount of weight. His experience has shown weight loss surgery to be most effective in ridding patients of the condition.

“If you can get the weight down, for a large proportion of those patients, their apnea goes away,” he said. “Increasingly, I’m developing a lot of very positive relationships with the bariatric surgeons.”

Regardless of the treatment method a sleep apnea patient chooses, it’s not likely to be an easy one, Dedrick said.